News From ACFAS

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If you couldn’t make it to the Fourth Annual ACFAS Job Fair in Las Vegas, you can still take advantage of the Job Fair virtually. Visit PodiatryCareers.org to post your resume online, view available jobs in your area or take advantage of ACFAS member discounts to post positions you’re trying to fill.

Next year's Job Fair at ACFAS 2018 in Nashville will include everything you've come to expect, plus expanded time with a professional resume reviewer. Watch for more details on how to participate as the event gets closer. The College’s 14 Regional Divisions once again provided financial support to resident and postgraduate fellow poster presenters and manuscript presenters at ACFAS 75 in Las Vegas last month.

Individual resident poster presenters received $250 in support, and resident manuscript presenters received $500. All supported poster and manuscript authors have been listed on acfas.org, along with links to their posters.

Interested in learning more about your local Division activities? Watch your email for updates on Division programs and events, or visit acfas.org for more information. The topic of disclosure came up in several sessions during ACFAS 75 in Las Vegas, and one issue discussed was breaking sterility in the OR.

What would you do if you had a break in sterile technique in your own OR? Take this month’s poll at right and let us know. Remember, you can view real-time results throughout the month at acfas.org.

Foot and Ankle Surgery

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The goal of researchers was to investigate the characteristics and results of realignment surgery for the treatment of malunited ankle fracture. Thirty-three patients with malunited fractures of the ankle who underwent reconstructive surgery at a hospital in Shanghai, China, from January 2010 to January 2014 were reviewed. The tibial anterior surface angle (TAS), the tibiotalar tilt angle (TTA), the malleolar angle (MA) and the tibial lateral surface angle (TLS) were measured, as were the American Orthopaedic Foot and Ankle Society's (AOFAS) scale and visual analogue scale (VAS) scores. Osteoarthritis stages were determined radiographically with the modified Takakura classification system. The Wilcoxon matched-pairs test was used to analyze the difference between the preoperative and the postoperative data. The mean follow-up was 36 months, while the mean age at the time of realignment surgery was 37.1 years. Compared with preoperation, the TAS at the last follow-up showed a significant increase and similar results were observed in TTA and MA. At the last follow-up, the mean AOFAS score was significantly increased compared with the score at preoperation. One patient had increased talar tilt postsurgery; the postoperative talar tilt angle of this patient was 20°. One patient had progressive ankle osteoarthritis and was treated by ankle joint distraction. The researchers concluded that realignment surgery for a malunited ankle fracture can reduce pain, improve function and delay ankle arthrodesis or total ankle replacement. Postoperative large talar tilt and advanced stages of ankle arthritis are the risk factors for the surgery.


A new study offers fresh evidence of the impact of smoking, obesity and alcohol overuse on the development of infections after surgery for a fracture of the ankle. Researchers retrospectively reviewed all patients who underwent internal fixation of a fracture of the ankle between 2008 and 2013. Associations with the risk factors and possible confounding variables were analyzed univariably and multivariably with backwards elimination. A total of 1,043 patients were included; 64 (6.1 percent) had a deep infection and 146 (14.0 percent) had surgical site infection. Obesity was strongly associated with both outcomes in all analyses. Alcohol overuse was similarly associated, though significant only in unadjusted analyses, and surprisingly, smoking did not yield statistically significant associations with infections. The findings suggest that obesity and possibly alcohol overuse are independent risk factors for the development of infection following surgery for a fracture of the ankle.


Rheumatoid arthritis (RA) is one of several types of inflammatory arthropathies resulting in foot pain and deformity. Many patients with this disease are now taking biologic agents, which pose several risks to patients in the perioperative phase, prompting researchers to review the current literature about perioperative foot and ankle surgery requirements for patients with RA receiving biologic therapy. The majority of the literature discusses the perioperative complications associated with patients on anti-TNFa therapy with few studies investigating the other biologics in common use. There is conflicting evidence as to the safety of continuing or stopping biologic drug therapy prior to orthopaedic procedures. The British Society for Rheumatology (BSR) has produced guidelines for the management of patients on anti-TNFa therapy or the biologic agent Tocilizumab. These recommendations suggest the risks of postoperative infection need to be balanced against the risk of a postoperative disease flare. In essence, it is suggested that anti-TNFa therapy is stopped three to five times the half-life of the drug while Tocilizumab is stopped four weeks prior to surgery. The researchers conclude that good communication is needed between the surgical team and the local rheumatology department managing the patient's disease in order to optimize perioperative care. Local pathways may vary from the BSR recommendations to determine the most suitable course of action with regards to continuing or stopping biologic therapy prior to foot and ankle surgery.

Practice Management

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Patients are trusting online reviews with increasing frequency, and medical practitioners should accept the fact that online reviews are a reality. Practices will have a better chance of performing well if they can leverage the power of positive online reviews, improving their online reputation. A proactive online reputation strategy can help current and prospective patients perceive a practice as an established, credible and authoritative medical resource, writes Manish Chauhan, digital marketing manager for myPracticeReputation, a reputation management solution for physicians. Practices should use tools like Google Alerts and Social Mention to monitor online conversations and should address reviews promptly and professionally. Another effective strategy is to use social media to engage patients and turn them into brand advocates. Moreover, practices should make sure business information is updated on third-party websites and search engines and should provide unmatched customer service. Online reputation management is a continuous activity, and a strong reputation cannot be built overnight, notes Chauhan. "This is why most doctors choose to hire professionals to help them improve the online reputation of their medical practice," concludes Chauhan.


Physicians looking to negotiate reimbursement rates with payers often find themselves dealing with take-it-or-leave-it offers, leaving them feeling frustrated and powerless. Physicians should not take the attitude of indifference as a final answer to negotiation attempts, according to experts. Instead, they should think of it as an opening round in what can often be a long process to get the attention of the right person in the insurance company. Experts say successful negotiation requires a thorough understanding of what value the practice offers the payer, a dogged determination to find the right decision-maker at the payer and the ability to sell the practice's attributes to that person. The first step is to figure out what value they bring to the payer. Things like current procedural terminology codes and frequency counts of Healthcare Common Procedure Coding System codes are important in creating a value proposition for the practice. Each practice must prioritize what is most important and negotiate hardest on the terms that matter most, using the data gathered during the preparation phase to make its case. Physicians should approach negotiations with the attitude of, "I'm willing to do whatever it takes to create some cost savings and add value, but I want a quid pro quo where we help each other out," says Nathaniel Arana, owner of healthcare consulting firm NGA Healthcare in Tucson, Ariz.


Rejected payer claims are a source of frustration for many practices, but there is something physicians can do about them, according to experts. Physicians should acknowledge that they are experiencing denials, identify the root causes and take steps to address those issues, says Maureen Clancy, senior vice president of revenue cycle management and credentialing at Privia Health. Practices should have someone monitor denials as they occur, invest in administrative staff and work the scrubber edits. They should have coders, billers or other members of the administrative staff identify and present the top five to 10 denials for the practice on a weekly basis, and this can serve as a teaching tool for physicians. “If it's done in the spirit of training and improvement—and not seen as punitive—it's usually very well-received,” says Clancy. When practices receive a denial, they should contact the insurer to determine exactly what information it needs to process the claim and provide this information consistently in the future, adds Patricia Cortez, practice administrator at Plano Internal Medicine Associates, PA in Plano, Texas. Practices should also review medication formularies before prescribing, understand medical necessity requirements, have someone monitor payer policies and, when possible, report specific diagnosis codes.

Health Policy and Reimbursement

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The American Medical Association (AMA), the Medical Group Management Association (MGMA) and several other healthcare organizations are urging the federal government to reduce the burden and penalties associated with electronic health records, meaningful use, Physician Quality Reporting System (PQRS) and Value-Based Payment Modifier (VBPM). In a letter to the recently confirmed U.S. Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma, the groups recommended that CMS create a new category within the existing hardship exemptions specifically for administrative burdens, not penalize eligible providers because of "arbitrary 'check the box' requirements" under meaningful use and offer relief for providers impacted by programs that predate MACRA. They also called for hardship exemptions for PQRS and VBPM. "As indicated in the MACRA law and final regulations, policymakers in Congress and the Administration clearly understand that fair and accurate measurement of physicians' performance will not be possible until better tools become available," the groups wrote. "We also believe the steps we have outlined are in keeping with President Trump's efforts to reduce regulatory burden." In addition to AMA and MGMA, the American Academy of Family Physicians, American College of Physicians, American Psychiatric Association, the Medical Society of the District of Columbia and 43 state medical societies signed the letter to CMS.


President Donald Trump and GOP lawmakers can regroup after failing to repeal the Affordable Care Act (ACA) by pursuing a House Republican legal challenge of payments insurers receive under the law. The lawsuit was suspended as Republicans pushed to replace the ACA, but it could now resume, or the Trump administration could decline to contest it and simply drop the payments. Such actions would stop the government payments reimbursing insurers for subsidies that lower the cost of deductibles, copayments and coinsurance for about six million people who obtain insurance on the ACA's exchanges. Insurers would lose billions of dollars in expected funding and would likely flee the ACA's exchanges, a foundation of the health law where millions of people obtain coverage. The path forward is unclear and insurers are pressing for a quick decision on the lawsuit as they decide whether to participate on the exchanges next year. The administration is still considering its options regarding the litigation, according to a White House spokesperson.


The U.S. Centers for Medicare and Medicaid Services (CMS) has postponed a rule that would slash Medicare payments to clinical labs by $3.93 billion over a decade. The rule reduces Medicare payments for lab tests to make them equal to private insurers' payouts, but CMS has pushed back the deadline for labs to submit private payer data from March 31 to May 30. The labs say they need the additional time to review and ensure the accuracy of their information. A study from the Department of Health and Human Services' Office of Inspector General found Medicare has historically paid between 18 percent and 30 percent more than other insurers for certain lab tests. Under the current fee schedule, each lab determines its own payment rates according to regional rates. The rule to cut Medicare payments, required by the Protecting Access to Medicare Act of 2014, is expected to save $390 million in its first year of enactment.

Medicine, Drugs and Devices

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The emergency room may be the next frontier in digital health. The Emergency Department Express Care program at NewYork-Presbyterian/Weill Cornell Medicine has expanded to a second location downtown and is now available 16 hours a day. The hospital launched the program in July with four-hour shifts with the goal of reducing waiting times and getting patients with non-urgent cases in and out of the emergency room efficiently without compromising care. The total amount of time spent in the ER has dropped to 35 to 40 minutes, from an average of 2 to 2.5 hours, according to Rahul Sharma, the emergency physician-in-chief at Weill Cornell. Sharma says he has received inquiries from more than a dozen hospitals and healthcare systems curious about the program, which has conducted more than 1,700 virtual visits. Critics of telemedicine have raised questions about quality of care being sacrificed for convenience, as well as the impersonal nature of a virtual care. However, emergency medicine experts believe such issues are not relevant because nurse practitioners and physician assistants conduct screenings and assist with care.


More surgery is being performed with the patient awake and looking on, for both financial and medical reasons. Choosing to watch your own surgery is one more manifestation of the patient autonomy movement. Dr. Alexander Langerman, senior author of a recently published awake procedures study and a head and neck surgeon on the faculty of Vanderbilt University Medical Center in Nashville, says the trend reflects a growing suspicion, generally, of authority figures. However, proponents like Dr. Asif Ilyas, a hand and wrist surgeon who operates at the Rothman Orthopaedic Specialty Hospital in Bensalem, Pa., praise awake surgery as a step forward in transparency. With patients having been exposed to graphic surgery on reality television shows and nighttime medical dramas, "They are primed to think they're ready to watch this," says Langerman. Surgery has also been partially demystified by doctors posting surgical videos on YouTube and live procedures on Snapchat. Still, many doctors are apprehensive about awake surgery because patients could become too anxious or distract them with too many questions, but they often have a fear of disappointing patients and also have concerns about litigation. Studies show that regional anesthesia has fewer complications than general anesthesia and is less expensive. Recovery time is swifter and side effects are fewer, which can reduce the need for postoperative opioids.


A team of researchers at the University of Bristol and NHS Blood and Transplant have developed a robust and reproducible technique allowing the production of immortalized erythroid cell lines from adult stem cells. These premature red cells can be cultured indefinitely, allowing larger-scale production before being differentiated into mature red blood cells. Dr. Jan Frayne, from the University of Bristol School of Biochemistry, says, "By taking an alternative approach, we have generated the first human immortalized adult erythroid line (Bristol Erythroid Line Adult or BEL-A), and in doing so, have demonstrated a feasible way to sustainably manufacture red cells for clinical use from in vitro culture." Prof. Dave Anstee observes, "Globally, there is a need for an alternative red cell product. Cultured red blood cells have advantages over donor blood, such as reduced risk of infectious disease transmission." NHS Blood and Transplant's first human clinical trials of manufactured blood are due to start by the end of 2017. The trials will use manufactured red cells from stem cells in a normal blood donation rather than Bel-A cells. "The first therapeutic use of a cultured red cell product is likely to be for patients with rare blood groups because suitable conventional red blood cell donations can be difficult to source," forecasts Anstee, who serves as director at the NIHR Blood and Transplant Research Unit in Red Cell Products. The research was published in Nature Communications.